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-#MiGr05G0piGal  Studies^^ 


■U"I=03Sr     THE 


llisorptioo  of  tlie  Roots  of  Temporarj  Teetk 


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WHITNEY   MEMORIAL   PRIZE    ESSAY   OF   THE   DENTAL   SOCIETY 
OF   THE   STATE   OF   NEW   YORK,    1S84. 


By    frank  rABBOTT,    M.    D 


RepHn'ed  from  the  IiVDEPEA'DEX T  PRACTITIONER  0/  July,  1884. 


NEW   YORK   DENTAL   juL'RNAL   ASSOCIATION, 
No.  35  West  4<ith  Street,  New  York. 


Microscopical  Studies  Upon  tlie  Absorption  of  the 
Roots  of  Temporary  Teeth. 


The  fact  that  temporary  teeth,  previous  to  the  appearance  of  the 
permanent  ones,  are  considerably  reduced  in  size,  often  lacking 
roots,  often  consisting  only  of  a  thin  shell,  and  exhibiting  a  cor- 
roded festooned  surface,  has  long  since  attracted  the  attention  of 
observers.  It  has  never  been  doubted  that  a  persistent,  though 
graded,  irritation  causes  the  absorption ;  but  what  the  real  cause  of 
this  irritation  is  we  cannot  tell.  The  idea  that  in  all  cases  the 
pressure  of  the  growing  permanent  tooth  is  the  direct  cause  must 
be  abandoned,  since  clinical  observation  shows  that  the  absorption 
of  a  temporary  tooth  may  take  place  though  far  distant  from  the 
permanent  one ;  nevertheless,  we  maintain  that  the  growth  of  the 
latter,  indirectly  at  least,  causes  the  irritation,  and  consequent 
absorption. 

The  assertion  of  Tomes  that  it  is  due  to  the  presence  of 
freely  vascularized  papilla  does  not  explain  the  decrease  of  the 
dental  tissues,  for  the  papilla  is  nothing  but  medullary  tissue, 
such  as  we  meet  with  in  any  part  of  the  organism  where  one  tissue 
is  about  to  change  into  another.  Such  a  papilla  can  be  the  cause 
of  the  absorption,  as  well  as  its  result.  Another  assertion,  that 
the  medullary  cells  eat  out  the  dental  tissues  by  their  active  growth, 
or  by  their  ameboid  motions,  is  insufficient  for  the  explanation  of 
the  loss  of  the  lime-salts  in  the  dental  tissue,  the  presence  of  circu- 
lar or  semi-circular  excavations  and  bays,  so  characteristic  of  the 
melting  process  of  the  cementum  and  dentine  of  deciduous  teeth. 

Since  we  know  that  pieces  of  dead  bone  or  ivory  may  be  absorbed 
with  figures  similar  to  those  found  on  the  surface  of  temporary 
teeth,  the  idea  j)ossibly  becomes  admissible  that,  owing  to  the 
presence  of  an  acid,  first  the  lime-salts  are  dissolved  out  within 


certain  territories  of  the  dead  bone  tissue  in  a  merely  chemical  or 
passive  way,  whereupon  the  soft  medullary  tissue  penetrates  the 
spaces  thus  established.  Quite  different,  however,  will  be  the  con- 
ception of  this  process  if  we  bear  in  mind  that  the  temporary 
teeth,  as  well  as  the  permanent  ones,  are  made  up  of  living  tissues, 
and  an  active  participation  of  these  tissues  must  be  expected  in  the 
process  of  transformation  of  the  dental  into  that  of  medullary 
tissue.  As  the  process  of  absorption  is  closely  allied  to  the  process 
of  inflammation,  and  active  changes  of  the  dental  tissues  have 
been  proven  to  follow  inflammation  beyond  any  doubt,  we  may  a 
priori  expect  such  changes  of  the  bone  tissues  of  the  temporary 
teeth  in  the  process  of  absorption  also.  I  shall  try  to  prove  in  this 
paper  that  such  changes  really  do  occur.  In  the  light  of  the  most 
advanced  modern  views  concerning  the  structure  of  the  dental 
tissues,  we  consider  cementum,  dentine,  and  enamel  as  endowed 
with  properties  of  life,  or,  in  other  words,  as  pervaded  by  living 
matter  in  the  shape  of  an  extremely  delicate  reticulum.  In  this 
view  not  only  the  cement  "corpuscles  and  their  coarser  offshoots 
contain  living  matter  in  the  shape  of  so-called  "  granular  proto- 
plasm," but  the  whole  basis-substance  present  between  the  cement 
corpuscles  is  alive  also,  only  the  minute  meshes  of  the  living  reti- 
culum holding  a  gluey  basis-substance  saturated  with  lime-salts. 
In  the  dentine,  not  only  the  tenants  of  the  dentinal  canaliculi  (the 
dentinal  fibers)  are  alive,  but  the  whole  mass  of  gluey  and  calcified 
basis-substance  between  the  dentinal  canaliculi  is  also  living.  The 
same  holds  good  for  the  enamel,  in  which  the  delicate  fibrilge  be- 
tween the  enamel  prisms  have  positively  been  proven  to  be  living 
matter,  but  the  prisms  are  pierced  by  living  matter,  though  the 
latter  has  not  been  demonstrated  directly,  but  indirectly  in  morbid 
changes  of  the  enamel.  Of  the  cementum,  we  know  that  each 
cement  corpuscle  occupies  the  center  of  a  more  or  less  globular 
territory  of  basis-substance.  If,  therefore,  circular  fields  of  absorp- 
tion appear  in  the  process  of  inflammation  and  absorption  of  the 
cementum,  we  can  readily  trace  these  territories  in  following  out 
the  portion  affected  by  the  process  of  absorption.  But  how  shall 
we  explain  the  bay-like  excavations  in  the  dentine  aad  enamel  so 


often  seen  in  reduced  temporary  teeth,  where  there  is  nothing 
known  of  territories?  Here  the  first  difficulty  sets  in,  due  to  the 
lack  of  knowledge  of  the  history  of  the  development  of  dentine 
and  enamel.  Czermak's  interglobular  spaces  indicate  the  presence 
of  such  territories  in  the  dentine,  the  presence  of  which,  however, 
can  be  proven  only  after  accurate  researches  in  the  history  of  devel- 
opment. 

Granted  that  the  dissolution  of  lime-salts  takes  place  in  globular 
territories  in  the  dental  tissues,  the  next  question  will  be,  how  do 
the  medullary  elements  appear  in  such  spaces  ?  Do  they  migrate 
or  penetrate  from  without,  or  do  they  originate,  in  part  at  least, 
from  the  living  material  present  in  all  dental  tissue  ? 

ABSOKPTION   OF   CEMENTUM. 

The  process  of  absorption  of  a  provisional  tooth  begins  on  the 
cementum  of  the  roots.  The  latter  exhibits  before  the  beginning 
of  this  process  the  features  of  cementum  of  permanent  teeth. 
Primarily,  the  absorption  is  marked  by  the  appearance  of  the 
well-known  fields  so  commonly  met  with  in  the  process  of  osteitis, 
that  is,  excavations  on  the  surface,  either  semi-circular  or  composed 
of  a  varying  number  of  semi-circular  festoons,  all  of  which  are 
filled  with  medullary  elements,  multinuclear  bodies,  or  a  delicate 
myxometa,  in  part  a  bony,  in  part  fibrous  connective  tissue,  blend- 
ing with  the  adjacent  myxometous  or  fibrous  pericementum.  The 
communication  of  the  excavations  with  the  pericementum  is  either 
widely  gaping  or  through  a  narrowed  neck  on  the  surface  of  the 
cementum.  Sometimes,  however,  in  the  sections  the  excavations 
appear  isolated,  without  any  communication  with  the  surface, 
which  latter  instance,  however,  will  certainly  not  entitle  us  to  deny 
the  existence  of  such  a  communication  on  a  plane  above  or  below 
that  of  the  section.  In  the  excavations  the  cementum  is  unques- 
tionably reduced  first  into  medullary,  afterward  into  myxometous 
or  fibrous  tissue.  By  closely  watching  excavations  of  a  more 
recent  date  at  the  periphery  of  those  in  communication  with  the 
pericementum,  we  notice  that  the  lime-salts  and  the  basis-substance 
proper   are   missing,  and   are   replaced   by  a   uniformly    granular 


protoplasm,  or  a  varying  number  of  faintly  marked  medullary 
elements,  each  of  which  may  contain  a  central  nucleus.  We  can 
trace  a  gradual  change  of  the  tissue  of  cementum  from  a  dissolu- 
tion of  lime-salts  to  the  appearance  of  a  mass  of  granular  proto- 
plasm, and  at  last  to  the  formation  of  medullary  corpuscles.  The 
circular  shape  of  the  excavation  is  in  all  cases  undoubtedly  due  to 
a  dissolution  of  the  lime-salts,  and  afterward  of  the  basis-substance 
proper,  within  the  territory  of  a  cement  corpuscle.  Sometimes  we 
see  an  enlargement  of  the  lacuna  and  the  cement  corpuscle  itself, 
the  latter  splitting  up  into  a  varying  number  of  glistening  lumps, 
which  are  readily  stained  by  an  ammoniacal  solution  of  carmine. 
In  other  instances  the  whole  territory  of  a  cement  corpuscle  is 
transformed  into  protoplasm,  and  the  reappearance  of  such  proto- 
plasm is  traceable  through  broad  offshoots  to  neighboring  cement 
corpuscles.  In  a  third  instance  a  varying  amount  of  the  territory 
has  assumed  a  delibate  fibrous  appearance,  caused  by  an  early  group- 
ing of  the  medullary  corpuscles  into  fibrillse.  In  neither  of  these 
instances  will  it  be  doubted  that  the  cement  corpuscles  themselves, 
or  the  living  matter  held  in  their  territories,  have  in  an  active  way 
taken  part  in  the  reappearance,  first  of  protoplasm,  and  afterward 
of  medullary  corpuscles.  The  theory  that  immigrated  medullary 
corpuscles,  or  "leucocytes,"  have  replaced  the  former  cement  tissue 
must  be  abandoned  as  soon  as  we  can  trace  a  gradual  transforma- 
tion of  the  tissue  of  the  cementum  into  medullary  tissue.  The 
latter  immediately  assumes  the  characteristic  features  of  a  myxome- 
tous  or  fibrous  connective  tissue,  in  connection  with  the  perice- 
mentum (Fig.  1). 

From  this  point  of  view  there  is  no  diflBculty  in  explaining  the 
appearance  of  multinuclear  bodies,  so-called  "  myelo-plaxes,"  in  the 
dissolved  territories.  We  know  that  such  formations  represent  a 
stage  of  development  of  cementum,  and  they  simply  reappear  as 
soon  as  the  basis-substance  of  an  already-formed  cementum  is  dis- 
solved or  liquefied.  In  fact,  nothing  else  is  required  but  a  reforma- 
tion of  basis-substance  and  its  recalcificatiou,  in  order  to  reproduce 
new  bony  tissue,  such  as  we  often  meet  with  on  the  periphery  of 
absorbed  cementum. 


The  result  of  the  absorption  is,  next  a  myxometous  or  fibrous 
connective  tissue  freely  supplied  with  newly-formed  blood  vessels. 


ea 


Fig.    1. — ABSORPTION  OF   CEMENTUM. 

C, — Cementum,  whose  corpuscles  are  in  part  in  a  process  of  division. 
F. — The  basis-substance  of  cementum  transformed  into  a  delicate  fibrous 
tissue,  in  connection  with  a  considerably  enlarged  and  split  up  cement  cor- 
puscle. M. — Multinuclear  protoplasmic  mass,  sprung  from  the  cementum 
after  liquefaction  of  its  basis-substance.  The  large  offshoots  of  this  mass 
show  the  process  of  transformation  of  the  basis-substance  into  medullary  cor- 
puscles. F.  C. — Fibrous  connective  tissue,  the  result  of  the  liquefaction  of 
cementum.     Magnified  500  diam. 

In  this  tissue  an  active  new  formation  of  bony  trabeculae  of  bone 
takes  place,  characterized  by  the  presence  of  large  and  irregular 
bone  corpuscles.  The  widened  socket,  or  dissolving  surface  of  an 
absorbing  provisional  tooth,  is  not  infrequently  filled  with  newly 
formed  bone.  The  newly  formed  layer  of  cementum  in  part  shows 
circular  fields  (territories)  of  bone  tissue,  each  of  which  may  con- 
tain a  varying  number  of  bone  corpuscles,  or  there  is  a  uniform 
reduction  of   the  original  cementum,  the  boundary  of    which   is 


made  up  by  regularly  arranged  medullary  corpuscles,  so-called  "os- 
teoblasts." 


Fig.  2. — ABSOBPnoN  op  neck  op  tooth. 
N. — Dentine  of  neck  of  tooth  not  supplied  with  canaliculi.  D. — Canali- 
culi  of  dentine  stopping  short  of  the  surface  of  the  neck.  B. — Bay-like  exca- 
vations in  the  middle  of  dentine,  filled  with  a  pale  and  finely  granulated 
protoplasm,  nuclei  beginning  to  appear.  G. — Excavation  filled  with  coarsely 
granular  protoplasm,  tending  toward  an  active  new  formation  of  medullary 
corpuscles.  M. — Multinuclear  protoplasmic  bodies,  the  so-called  "myeloid 
cells,"  in  connection  with  fibrous  connective  tissue  on  the  surface.  Magnified 
600  diam. 

On  the  neck  of  the  tooth  the  excavations  penetrate  not  only  the 
layer  of  the  cementum  proper,  but  also  the  layer  of  the  subjacent 
dentine,  which  we  know  to  be  destitute  of  dentinal  canaliculi.  Here 
again  we  observe  at  first  a  dissolution  of  the  basis-substance  in 
globular  fields,  which  appear  filled  at  first  with  a  finely  granular 
protoplasm,  lacking  nuclei,  afterward  with  usually  nucleated  med- 
ullary corpuscles,  and  at  length  with  a  slightly  fibrillated  tissue,  the 
latter  undoubtedly  originating  from  a  splitting  of  the  medullary 
corpuscles  into  a  number  of  delicate  spindles.     The  surface  of  the 


neck  of  the  tooth  likewise  exhibits  the  characteristic  bay-like  ex- 
•cavations  which  are  filled  with  nucleated  medullary  corpuscles,  or 
with  multinuclear  protoplasmic  bodies.  From  Avhat  I  have  seen,  I 
cannot  doubt  that  the  nuclei  under  all  circumstances  are  secondary 
formations,  and  cannot  be  regarded  as  the  future  bone  corpuscles. 
A  territory  of  bone  tissue  will  form  only  after  the  protoplasm  has 
assumed  a  uniform  granulation,  and  the  bone  corpuscles  will  develop 
out  of  this  protoplasm,  by  an  increase  of  living  matter  at  certain 
regular  intervals.  The  result  of  the  absorption  and  reappearance  of 
the  embryonal  condition  of  the  tissues,  constituting  the  neck  of  the 
tooth,  results  in  the  formation  of  new  bone  tissue,  either  in  the 
shape  of  globular  fields  (territories)  of  newly-formed  bone  tissue,  or 
in  the  formation  of  a  thin  layer  of  regularly  lamellated  bone  tissue, 
blending  with  that  formed  out  of  the  cementum  of  the  roots. 

Bodecker,  in  his  article  on  the  distribution  of  the  living  matter 
in  the  dentinal  tissues  (Dental  Cosmos,  1878-79),  describes  and 
illustrates  the  neck  of  a  tooth,  calling  it  an  anomalous  formation  of 
cementum.  From  what  I  have  seen  I  cannot  doubt  that  his  figure 
is  taken  from  a  deciduous  tooth,  exhibiting  newly-formed  bone 
tissue  on  the  neck.  Unquestionably  such  bony  formations  are  not 
lasting,  but  are  reformed  into  medullary  tissue  with  the  advancing 
absorption  of  the  dental  tissues,  either  leading  to  the  formation  of 
new  bone  or  of  fibrous  connective  tissue. 

ABSORPTION   OF   DENTINE. 

The  most  striking  features  in  the  dentine  of  deciduous  teeth  are 
the  bary-like  excavations  on  the  surface  after  a  complete  disappear- 
ance of  the  covering  cementum.  The  excavations  contain  medul- 
lary corpuscles,  multinuclear  bodies,  or  fibrous  connective  tissue,  in 
connection  with  the  surrounding  pericementum,  or  periodontium. 
The  appearance  of  such  fields  in  the  dentine  gave  rise  to  the  theory 
that  a  foreign  tissue  grows  into  the  dentine,  destroying  it  in  the 
manner  in  which  dead  bone  is  destroyed.  If,  however,  we  bear  in 
mind  that  the  tissue  of  dentine  is  composed  of  globular  territories, 
the'same  as  that  of  bone,  we  at  once  are  in  the  position  to  under- 
stand the  striking  appearance  of  globular  fields  of  absorption  in  the 


dentine.  The  question  can  only  be,  is  the  dentine  absorbed  in  a 
merely  passive  way,  or  does  it  share  in  the  formation  of  medullary 
tissue,  so  long,  at  least,  as  it  is  the  seat  of  life  in  itself?     My  re- 


FIG.   3. — ABSOBPTION   OP   DENTINE. 

D. — Dentine  provided  with  unchanged  canaliculi.  B. — Bay-like  excavation 
in  the  dentine,  containing  finely  granular  protoplasm,  which  is  about  to  form 
medullary  corpuscles.  F. — Medullary  corpuscles  elongated  and  split  into  deli- 
cate spindles,  the  future  fibrous  connective  tissue.  M. — Globular  protoplasmic 
masses,  the  predecessors  of  globular  territories  of  bone  tissue,  Q. — Globular 
territories  of  bone  tissue,  with  central  bone*corpuscles.  L. — Lamellated  bone 
tissue  surrounding  the  outer  surface  of  the  absorbed  tooth,  or  the  inner  surface 
of  its  socket.    Magnified  600  diam. 

searches  strongly  point  in  favor  of  an  answer  in  the  latter  direction. 
In  several  instances  I  have  been  able  to  trace  a  slight  widening  of 
the  dentinal  canaliculi  on  the  border  of  the  fields  of  absorption, 
with  an  increase  of  living  matter  in  the  canaliculi.  Such  features 
are  very  common  in  the  process  of  caries,  where  the  dilatation  of 
the  canaliculi  at  the  expense  of  the  intervening  basis-substance,  and 
a  new  formation  of  medullary  elements  out  of  the  tenants  of  the 
canaliculi,  is  a  very  common  occurrence,  provided  that  the  caries 
attacks  the  living  dentine.  Circumscribed  bay-like  excavations, 
such  as  are  common  in  the  absorption  of  dentine,  I  have  frequently 
met  with  in  caries. 


9 

Sometimes  such  excavations,  in  caries,  form  independently  of  the 
surface  destruction,  and  with  the  lower  powers  of  the  microscope 
even  a  well-versed  eye,  under  these  circumstances,  would  experience 
difficulty  in  discriminating  between  carious  destruction  and  absorp- 
tion of  temporary  dentine.  Higher  powers,  to  be  sure,  reveal  the 
presence  of  micro-organisms  in  the  former  process,  which  are  lack- 
ing in  the  latter.  The  first  step  seems  to  be  identical  in  both  in- 
stances; a  dissolution  of  the  lime-salts,  or  a  displacement  of  the 
lime-salts,  by  the  liquefaction  of  the  glue  giving  basis-substance. 
After  this,  medullary  elements  arise  out  of  the  liquefied  dentine 
which  are  destined  to  decay  in  caries,  and,  on  the  contrary,  pro- 
liferate in  the  process  of  absorption,  with  the  result  of  the  new 
formation  of  medullary  tissue.  In  caries  the  process  of  softening, 
or  the  removal  of  the  calcified  basis-substance,  results  in  the  death 
and  putrefaction  of  the  tissue ;  that  is,  its  replacement  by  micro- 
organisms. In  the  process  of  absorption,  on  the  contrary,  it  ends 
in  an  active  proliferation  of  medullary  tissue,  with  the  non-inter- 
ference of  micro-organisms. 

The  result  of  the  latter  process  is  the  same  whether  it  occurs  on 
the  cementum,  on  the  neck  of  the  tooth,  or  in  canalicularized  den- 
tine. The  newly-formed  medullary  tissue  consists  either  of  single 
medullary  corpuscles,  usually  with  one  oblong  and  faintly-marked 
nucleus,  or  in  the  shape  of  larger  protoplasmic  masses  with  a  vary- 
ing number  of  oblong  nuclei,  so  called  "  myeloid  cells."  At  the 
border  of  the  bays  I  have  sometimes  been  able  to  trace  delicate 
thorny  projections  from  the  multinuclear  masses  into  the  unchanged 
basis-substance  of  the  dentine.  Sometimes  I  have  seen  broad  off- 
shoots of  the  multinuclear  bodies  penetrating  the  widened  dentinal 
canaliculi,  and  in  direct  union  with  the  dentinal  fibers.  The  latter 
feature,  especially,  seems  to  point  strongly  toward  an  organic  con- 
nection between  the  unchanged  and  the  dissolved  out  dentine. 

The  multinuclear  bodies  are,  as  is  well  known,  the  future  terri- 
tories of  bone  tissue,  and  therefore  predecessors  of  bone  tissue.  The 
formation  of  bony  territories  can  easily  be  traced  on  the  surface  of 
absorbed  dentine.  Just  as  in  normal  development  of  bone  tissue 
globular  territories  first   appear,  and   afterward   lamellated   bone 


10 

tissue,  so  also  iu  absorbed  dentine,  first  multinuclear  bodies,  after- 
ward globular  territories  of  bone  tissue,  and  at  last  lamellated  bone 
tissue  forms  on  the  surface,  the  latter  producing,  in  many  instances, 
a  continuous  layer  of  bone  all  around  the  absorbed  tooth.  This 
feature  is  correctly  observed  and  described  by  Tomes. 

As  to  absorption  of  the  enamel  I  can  say  but  little.  It  is  well 
known  that  bay-like  excavations  are  seen  in  this  tissue,  in  no  way 
differing  from  those  of  cementum  and  dentine.  From  this  fact  it 
would  follow  that  all  the  theories  hitherto  advanced  with  regard  to 
the  development  of  enamel  must  be  erroneous,  and  there  must  be 
an  arrangement  in  the  enamel  forming  tissue  leading  to  the  produc- 
tion of  territories  in  a  manner  similar  to  that  of  dentine  and 
cementum.  It  seems  that  the  process  of  destruction,  starting  on 
the  surface  of  the  enamel,  is  in  all  instances  caries,  and  not  absorp- 
tion. The  latter  process  attacks  enamel  only  from  within.  After 
most  of  the  dentine  has  been  absorbed  and  transformed  into  myxome- 
tous  tissue,  the  enamel  is  attacked  and  thinned  to  a  varying  degree 
by  the  same  process.  Thus  it  becomes  intelligible  that  the  shell  of 
enamel  left,  is  coated  by  a  layer  of  lamellated  dentine,  which  is  con- 
tinuous all  around  the  remnants  of  the  provisional  tooth. 

Since  we  know  that  enamel  is  a  live  tissue  in  a  living  tooth,  we 
may  anticipate  its  reduction  into  medullary  tissue  in  the  process  of 
absorption.  Whether  or  not  such  a  breaking  down  of  enamel  occurs 
and  its  consequent  participation  in  the  formation  of  bone  tissue,  I 
am  unable  to  say. 


THE  INDEPENDENT  PRACTITIONER. 

VOLUME  V,  1884. 


A  PRACTICAL  MEDICO-DENTAL  JOURNAL, 


EDITED  AND  PUBLISHED  BY 


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